Long-Term Care & Disability / ERISA

Long-term care and disability claims involve ongoing benefit determinations and are frequently governed by ERISA, which imposes specific content requirements on denial notices and appeal procedures that override state insurance law for employer-sponsored plans.

Key Correspondence Patterns

Benefit Determinations

• Initial determination — Approve or deny the claim with specific findings on the definition of disability or benefit eligibility
• Continuing-eligibility reviews — Periodic letters explaining whether benefits will continue, be reduced, or be terminated, and why
• Change of definition — Many policies shift from "own occupation" to "any occupation" after 24 months; the transition letter must explain the new standard

ERISA Requirements

• Adverse benefit determinations — Must include specific reasons for denial, relevant plan provisions, description of additional information needed, and appeal procedures
• Full and fair review — Claimants have the right to review the claim file and submit additional evidence
• Deadlines — ERISA imposes strict timelines for initial determination (45 days, extendable) and appeal decisions (45 days for disability, 60 days for other claims)

Long-Term Care

• Eligibility determinations — Based on activities of daily living (ADL) assessments or cognitive impairment criteria
• Care-plan correspondence — Letters explaining what services are covered, benefit periods, and elimination-period status

Common Errors

• Not disclosing the specific clinical or vocational basis for a disability denial
• Failing to provide the claim file on request
• Missing ERISA deadlines, which can result in deemed approval
• Using "any occupation" language during the "own occupation" period